Provider Demographics
NPI:1235861766
Name:SHADRACH, JEFFREY THOMAS (AGNP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:SHADRACH
Suffix:
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 SILO HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-7121
Mailing Address - Country:US
Mailing Address - Phone:417-844-2669
Mailing Address - Fax:
Practice Address - Street 1:13655 RIVERPORT DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-4812
Practice Address - Country:US
Practice Address - Phone:314-592-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021044288363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology